APOE genotype influences acquisition and recall following traumatic brain injury.

APOE has been demonstrated to influence traumatic brain injury (TBI) outcome. The relationship between APOE genotype and memory following TBI was examined in 110 participants in the Defense and Veterans' Head Injury Program. Memory performance was worse in those who had an APOE epsilon 4 allele (n = 30) than those who did not (n = 80), whereas genotype groups did not differ on demographic or injury variables or on measures of executive functioning. These data support a specific role for the APOE protein in memory outcome following TBI, and suggest an APOE isoform-specific effect on neuronal repair processes.

Thoracoscopic spine release before posterior instrumentation in scoliosis.

Surgical repair of severe deformities of the spine requires first stage surgery to acquire flexibility between the vertebrae in the deformed area. The standard technique for anterior surgery is through a thoracotomy and excision of the discs between the vertebrae with or without bone graft. A thoracotomy has several known and common risk factors, including breathing difficulties, a painful scar, and chronic postoperative pain. The development of endoscopic methods during the past decade, including video assisted thoracoscopy, has opened new horizons and technical challenges in spinal surgery. The morbidity and mortality associated with the use of the thoracoscope are minimal in comparison with the traditional thoracotomy. Three cases are presented in which the new surgical technique was used. The intervertebral discs in the deformed area were partially excised with the aid of video assisted thoracic surgery, and because of the flexibility acquired between the vertebrae in the anterior thoracoscopic approach, the second stage operation could be performed through a posterior approach. There was 58% and 68% improvement of the idiopathic scoliotic deformity in 2 patients and almost 42% in the patient with congenital wedge vertebra. As far as is known, these are the first 3 cases reported in which thoracoscopic anterior spinal release was used in the treatment of scoliosis.

Bone marrow infusion in adults.

OBJECTIVE: To asses the feasibility and success rate of vascular access through intraosseous infusions in adults, in elective and emergency situations using a novel, automatic device, the bone injection gun. DESIGN: A prospective, nonrandomized trial. MATERIALS AND METHODS: Two groups of patients were prospectively selected over an 11-month period. Group 1: Adult patients with recent closed long bone fractures, who underwent orthopedic surgery to upper and lower limbs and needed regional anesthesia. Group 2: Adult patients who required emergency or semiemergency vascular access, in whom intravenous central or peripheral cannulation could not be established within a reasonable period of time. MAIN RESULTS: Fifty adult patients, aged 27 through 78 years, underwent the procedure, which was universally successful. In group 1, n = 31 patients; in group 2 (n = 19), 12 patients had multiple injuries, and seven underwent emergency resuscitation. In 76% of the cases, the needle was inserted into the area of the tibial tuberosity; in the reminder of the cases, the needle was inserted at the distal end of the radial bone and into the lateral or the medial malleolus. The success rate for an adequate insertion was 100% in this group of patients. No complications from the procedure were observed in this series. CONCLUSIONS: This study emphasizes the importance and feasibility of the intraosseous route for infusion of fluids and medications in emergency situations in adults. The use of an impact, high speed automatic needle insertion device provides a higher success rate of vascular access via the intraosseal route in adult patients.

Posterior approach for radical excision of sacral chordoma.

Sacral chordoma is a rare primary malignant tumour of bone. Operations to excise these tumours are complex, time consuming and involve considerable blood loss. We describe the use of a posterior approach to excise chordomas from the sacrum of five patients without visceral involvement. This approach is less complex than combined approaches previously described. No distal recurrences had occurred at a mean followup of 5 years. One patient developed local recurrence and was successfully treated by wide local excision. Postoperative morbidity was low with regard to urinary and faecal continence problems. We recommend the use of Mersilene mesh to prevent herniation through the sacral defect.

Intraosseous regional anesthesia as an alternative to intravenous regional anesthesia.

A series of 109 orthopedic operations was performed under intraosseous regional anesthesia on the upper and lower limbs. Anesthesia was satisfactory in 106 of the cases; in the other three, inadequate anesthesia was caused by faulty technique. The spread of lidocaine into the bone and venous network was demonstrated by radiography, and the blood levels after tourniquet release were below the toxic level. Intraosseous regional anesthesia proved to be a valuable technique to be used whenever intravenous anesthesia fails or is not feasible. Injection into cancellous bone (osteoclysis) is easily and quickly performed under aseptic conditions, and there were no systemic complications.

Suppression of corneal allograft rejection by systemic cyclosporine-A in heavily vascularized rabbit corneas following alkali burns.

Immunologic rejection is the main cause of corneal graft failure, especially in vascularized corneal beds. The purpose of this study was to investigate the effect of systemic Cyclosporine-A (CsA) on the survival of corneal allografts in heavily vascularized rabbit corneal beds, following alkali burn. Heavy corneal vascularization was induced in one eye of 20 rabbits by alkali burn. Forty-five days later, penetrating keratoplasty was performed in all the heavily vascularized corneas. Twenty-five mg/kg/day of CsA was intramuscularly administered to 10 rabbits for 30 days. The other 10 rabbits were treated with the solvent without CsA and were used as a matched control group. The results show a significant difference in corneal allograft survival between the two groups. All corneal grafts in the untreated group were intensely rejected and vascularized within 3 weeks. Nine of the 10 corneal transplants, in the CsA-treated group, remained transparent without signs of immunologic rejection for > 180 days. In one corneal transplant, minor signs of rejection occurred. We suggest that CsA, when given systemically, is a potent drug in the prevention of immunologic rejection in high-risk corneal transplantations, such as allografts, in heavily vascularized corneas following alkali burn.

Hipoglicemia associada a tumor extrapancreático / Hypoglycemya associated with extra-pancreatic tumor

Os autores descrevem o caso de uma mulher de 51 anos, portadora de massa torácica extrapulmonar, que apresentou episódios de hipoglicemia sintomática dejejum. Esse quadro reverteu após a retirada cirúrgica de um mesotelioma pleural benigno, que pesava 1.800g. Sao discutidos os mecanismos de hipoglicemia tumoral extrapancreática em face de níveis indetectáveis de insulina, como em nosso caso.

[Percutaneous trephine for vertebral biopsy].

We performed percutaneous vertebral biopsy on 18 patients (March 1978 to March 1992) using a Craig trephine needle under fluoroscopic control, a more reliable and safer procedure than open vertebral body biopsy. Material for histopathologic examination was obtained in 17 of the 18 patients and there were no complications. Possible complications involve mostly in the cervical and dorsal spine. They can be prevented by using very precise and delicate technique under reliable fluoroscopic control in the operating room.

[Conservative treatment of CSF leakage after lumbosacral operations].

CSF leakage through a postoperative lumbosacral wound is an uncommon complication. It may result from excessive traction on nerve roots, or direct trauma or laceration at operation, causing inadvertent opening of the dura (1,4). Other reasons for this complication are residual bone spikes postlaminectomy, traumatic myelography puncture (2), and improper suture of dural defects. We examined 8 patients who had postoperative CSF leakage as the sole complication of lumbosacral spinal operations. They were all treated conservatively with bed rest in the Trendelenburg position, antibiotic coverage, watertight skin suturing and daily subcutaneous puncture. Each patient had been operated on for a different condition.

Postoperative cerebrospinal fluid leakage after lumbar spine operations. Conservative treatment.

Cerebrospinal fluid (CSF) leakage from a postoperative wound after lumbar spine operation is an uncommon complication. It may result from excessive traction of the nerve roots, direct trauma, or laceration at the time of operation, causing the dura to be inadvertently opened. Other reasons for this complication are postlaminectomy residual bone spikes, traumatic myelography puncture, and improper suture of dura defects. Eight patients who had postoperative CSF leakage as the only complication after lumbosacral spine operations were examined. They were all treated conservatively with bed rest in the Trendelenburg position, antibiotic coverage, watertight skin suturing, and daily subcutaneous punctures. No patient was operated on for the same type of complication.

[Posterior approach for excision of sacral chordoma].

Chordoma is considered to be a malignant, fatal tumor. According to most authors it constitutes between 1-4% of all malignant bone tumors. In 50% of the cases it is located in the sacrum, in 35% in the cervical spine and skull, and in 15% in the thoracic spine and elsewhere. It is an aggressive, locally invasive, slowly-growing tumor. Although metastases are rare, when they occur they are of an anaplastic type, especially in the lungs, liver, regional lymph nodes, skin and muscles. Chordoma is a rare tumor, and its location and slow growth often result in delayed diagnosis. Complete excision of the chordoma was formerly considered impossible. There is often local recurrence, and often, by its very nature, excision results in neurological defects. Lately, there is more optimism regarding complete cure, due to more advanced surgical methods. We present a 66-year-old man in whom a tumor developed in the sacrococcygeal area and the right buttock. The tumor was diagnosed by CT, MRI and biopsy as a chordoma of the sacrum, without intra-abdominal infiltration. He was operated through a posterior approach, with complete resection of the tumor, including almost the whole sacrum and the coccyx. We consider this approach simpler than the abdominal-dorsal approach, which in cases of intra-abdominal infiltration is necessary. We regard this simple incision as a significant advance in the treatment of this condition.(ABSTRACT TRUNCATED AT 250 WORDS)

Pityriasis rotunda.

Pityriasis rotunda affects dark-skinned persons and appears as nearly perfectly round or oval scaling patches. Often associated with chronic and debilitating illness or malignant disease, it is probably a localized variant of acquired ichthyosis.

Contact dermatitis caused by Brucella.

We report a case of a distinctive dermatitis in a dairy worker exposed to Brucella abortus while manually delivering an infected calf. The rapid onset of pruritus, the strict limitation of lesions to the upper extremities, and the negative results on growth of culture for microorganisms make direct bacterial infection an untenable cause in this case. Allergic hypersensitivity is the probable mechanism, manifesting itself initially as contact urticaria. Coincidentally our patient also had systemic brucellosis, the symptoms of which antedated and were unrelated to his cutaneous disease.

Bowen's disease of the palm.

Bowen's disease is a squamous cell carcinoma characterized by isolated, grouped or confluent nodules, either flat, scaling, or crusted, with an arcuate or serpiginous configuration. Malignant dyskeratosis throughout the epidermis, the bowenoid hallmark, is not sufficient by itself to identify a lesion as Bowen's disease. It has been suggested, but not proven, that arsenic has a role in the etiology of Bowen's disease. A case of Bowen's disease affecting the palm, an unusual location, is reported.